abdomen anak

7/27/2019 Abdomen Anak

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ABDOMINAL PEDIATRIC

Dr. Lydia Kuntjoro



Atresia ani

• Bisa terbentuk fisula : perianal fistula,

urogenital trackt fistula

• Anomaly yang sering terjadi

• bisa dinilai berdasar pemeriksaan fisik

• Perlu dipikirkan kelainan trisomi 21

Foto polos abdomen :• Post natal periode, udara mencapai rektum 6-

12j



• Memberikan gambaran distal gastrointestinal

obstruction dilatasi dan distensi

• Bila ada fistula ke traktus urinarius : udara

mengisi vesika urinaria, adanya kalsifikasi

meconeum didalam bladder

Pemeriksaan dengan kontras :

• Px dg kontras water-soluble

• Px fistulografi



Hirschprung’s disease

• Tidak adanya struktur normal pleksus nervusmyenterikus pada GIT distal

• Adanya g3 peristaltik pada area aganglionik

daerah yg sempit• Panjangnya segmen usus yang aganglionik

bervariasi

•>> mengenai : sigmoid, rektosigmoid, yang jarang pd colon descenden, rektum, colonsegmen lainnya, jarang di usus halus.



• Newborn obstipasi disertai tanda2 obstruksi

usus bag distal

• Keterlambatan pasase meconeum

• Ampulla rekti basanya kolaps pada palpasi

• Jenis nya :



• Foto polos : gambaran distal bowel obstruction

dengan retensi massive fecal material

• Px kontras : barium enema.

– Jangan dilakukan laksansia dan wash-out sebelum px

barium enema

– Wash-out setelah pemeriksaan dg barium stone

formation

– Isi kontras sampai di temukan segmen transisional

– Jk tidak ditemukan, delayed foto after 24 jam.



Necrotizing Enterocolitis

• Merupakan ischemic and infection boweldisease primarily of premature infants

• Simptoms: abdominal distention, blood in

stool, diarrhea, vomiting, increased biliousgastric residue, shock death

• Plain abdominal ro : AP / LLD dg delay time -

free air• Terjadi separasi loop usus oleh karena edema

atau intramural hemorrhage dinding usus



• Focal atau diffuse dilatation usus halus

• Pada keadaan advance : pneumatosis

intestinalis linier atau vesikuler

• Sulit dibedakan dengan udara-fekal material

• Ringlike pattern

•

Pada keadaan severe : intrahepatic portalvenous branches dapat menjadi perforasi ( gb.

Lig falciforme, football, Rigler’s



• Etiology Remains unknown

• Ischemia and/or reperfusion injury may play a role

• Translocation of intestinal flora across compromisedmucosa may play a role

• Incidence and age at onset More common inpremature infants , but can also be seen in term babies

•

Term infants develop NEC earlier after birth thanpreemies

– Average age of onset occurs within first week of life

– Affected term neonates are usually systemically ill withother conditions such as birth asphyxia, respiratory

distress or congenital heart disease

• Premature babies are at risk for several weeks afterbirth



• Clinical findings

– Feeding intolerance

– Delayed gastric emptying

– Abdominal distention and/or tenderness

– Ileus/decreased bowel sounds

• Imaging findings :>> terminal ileum

– Dilated loops of bowel

– Thickened bowel walls

– Pneumatosis intestinalis

• Pathognomonic of NEC in newborn

– Linear radiolucency parallels bowel lumen within bowel wall

– Represents air that has entered from the lumen



• Abdominal free air

– May require a left lateral decubitus view to be seen

• Portal venous gas

– Appears as linear branching areas of decreased

density over periphery of the liver

• Represents air in portal venous system

•

Ascites – Late finding

– Develops after perforation when peritonitis is present



• The plain abdominal film shows air in the portal vein, air in thebowel walls, and a largepneumoperitoneum [subdiaphragmatic free air, perihepatic free air,double wall sign (bluearrows), triangle sign (green arrows), and falciform ligament (red

arrow)].

• In the right lower abdomenthere is air in the bowel walls(pneumatosis intestinalis).



HPS

• 2-6 minggu

• Muntah proyektil, non-bilious vomiting,

palpable mass pada regio pilorus , menyerupai

“ olive”, dehidrasi, g3 metabolik, penurunan

BB

• FPA : dilatasi gaster, tdk ada udara usus diusus

halus, air-fluid level

• Sonogram :



• Age Usually manifests at 2-8 weeks of life

• Clinical Nonbilious projectile vomiting with

progression over a period of several weeks

after birth (15-20%)

• Palpable olive-shaped mass (80% sensitive in

experienced hands)

• Positive family history Nasogastric aspirate

>10 ml



• Pyloric wall thickness >10 mm

• Elongation and narrowing of pyloric canal (2-4 cm in length)

• "Double / triple track sign" – Crowding of mucosal folds in pyloric channel

• "String sign" – Passing of small barium streak through pyloric channel

• Twining recess = "diamond sign"

– Transient triangular tentlike cleft / niche in midportion of pyloriccanal with apex pointing inferiorly secondary to mucosal bulgingbetween two separated hypertrophied muscle bundles on thegreater curvature side within pyloric channel

• "Pyloric teat" –

Outpouching along lesser curvature due to disruption of antralperistalsis

• "Antral beaking" – Mass impression upon antrum with streak of barium pointing

toward pyloric channel



• Kirklin sign = "mushroom sign" – Indentation of base of bulb (in 50%)

• Gastric distension with fluid

• Active gastric hyperperistalsis – "Caterpillar sign"

• Gastric hyperperistaltic waves

• US findings "Target sign" – Hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa

centrally on cross-section

• "Cervix sign" – Indentation of muscle mass on fluid-filled antrum on longitudinal section

• "Antral nipple sign" – Redundant pyloric channel mucosa protruding into gastric antrum

• Pyloric volume >1.4 cm3 (= 1/4 ÷ x [maximum pyloric diameter]2 x pyloriclength) – Most criteria independent of contracted or relaxed state

• Pyloric length (mm) + 3.64 x muscle thickness (mm) > 25

• Pyloric muscle wall thickness >3 mm

• Pyloric transverse diameter >13 mm with pyloric channel closed

• Elongated pyloric canal >17 mm in length

• Exaggerated peristaltic waves

• Delayed gastric emptying of fluid into duodenum



• Fig. 23.1 A-F. More common radiographic signs of

infantile hypertrophic pyloric stenosis (after Astley,1952). A Central "beak". B Beak with adjacent concaveindentations (shoulder sign). C Beak, gap and cap. D String sign. E Longitudinal mucosal folds. F Concaveindentation base of cap. Pyloric "tit" (arrow)



Intususepsi



Meconeum Plug Synd



• Supine frontal view of the abdomen in anewborn withmeconium plug

syndromedemonstrates multipledilated loops of bowelbut no rectal gas.



Findings:

• The initial radiograph : moderately distended loops of bowel,distention and failure to pass meconium,: suggest a low GI tractobstruction and contrast enema

• The contrast enema (performed with water soluble contrast) :narrow rectosigmoid and descending colon, with a transition to alarger caliber at the upper descending colon/splenic flexure. Fillingdefects in this portion of the colon are indicative of meconiumplugs. The location of the transition is typical of meconium plugsyndrome (neonatal small left colon syndrome).

• The abnormality is due to functional immaturity of the colon in thenewborn. Meconium becomes impacted in the colon, and theinfant presents with distention, delayed passage of meconium, andmay have emesis.

• Associated conditions include: Prematurity, Maternal

diabetes,Maternal drug ingestion • When meconium plug syndrome is suspected, water soluble

contrast dx &tx helping to expel the meconium plugs from thecolon and relieve the obstruction



Differential Diagnosis:

• Hirschsprung disease :transition zone >>rectosigmoid colon. Atransition in caliber at the splenic flexure could occur with a long-segment Hirschsprung disease and could mimic this finding;

however, that is relatively rare in comparison with meconium plugsyndrome. Rectal biopsy should be considered if symptoms of constipation and/or obstruction persist but may not be necessary inall cases of meconium plug syndrome.

• Meconium ileus is impaction of meconium more proximally, usuallyin the terminal ileum. This is associated with the abnormallytenacious meconium in infants with cystic fibrosis. While theseinfants may also benefit from the therapeutic effects of watersoluble contrast enema, the obstruction is often more severe andmay require repeated contrast enema to relieve the obstruction.Abdominal radiographs often demonstrate a soap-bubble pattern inthe right lower quadrant, and contrast enema demonstrates a verysmall colon or "microcolon" with the obstructing meconium in thedistal ileum. Infants with meconium ileus require subsequenttesting for cystic fibrosis.



Volvulus (sigmoid)



General Considerations

• Twisting of loop of intestine around its mesentericattachment site may occur at various sites in the GI

tract – Most commonly: sigmoid & cecum

– Rarely: stomach, small intestine, transverse colon

– Results in partial or complete obstruction

– May also compromise bowel circulation resulting in

ischemia

• Sigmoid volvulus most common form of GI tractvolvulus – Accounts for up to 8% of all intestinal obstructions

•Most common in elderly persons (neurologicallyimpaired)

• have a history of chronic constipation

Pathophysiology



Pathophysiology

• Redundant sigmoid colon that has a narrow mesentericattachment to posterior abdominal wall allows closeapproximation of 2 limbs of sigmoid colon à twisting of sigmoid colon around mesenteric axis

• Other predisposing factors

– Chronic constipation

–

High-roughage diet (may cause a long, redundant sigmoidcolon)

– Roundworm infestation

– Megacolon (often due to Chagas dz)

• 20-25% mortality rate

• Peak age > 50 yrs.

– Second largest group à children

• Torsion usually counterclockwise ranging from 180 –

540 degrees



• Signs and symptoms May present as

abdominal emergency :Acute distension,

Colicky pain (often LLQ)Failure to pass flatus

or stool (constipation is prevailing feature),Vomiting is late sign

• Physical examination Tympanitic abdomen,

Abdominal distention



Diagnosis

• Abdominal plain films usually diagnostic – Inverted U-shaped appearance of distended sigmoid loop

– Loss of haustra

– Coffee-bean sign à midline crease corresponding tomesenteric root in a greatly distended sigmoid

• Sigmoid volvulus – bowel loop points to RUQ

• Cecal volvulus – bowel loop points to LUQ – Dilated cecum comes to rest in left upper quadrant

–Bird’s-beak or bird-of-prey sign à seen on barium enema asit encounters the volvulated loop

• CT scan useful in assessing mural wall ischemia



Atresia esofagus



Atrsia-stenosis duodenum



Thank you

abdomen anak

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